Fibromyalgia Primary Care Project - in1touchmpha.in1touch.org/uploaded/38/web/documents/Namaka MPHA...
Transcript of Fibromyalgia Primary Care Project - in1touchmpha.in1touch.org/uploaded/38/web/documents/Namaka MPHA...
Disclosure
This program was developed by the
University of Calgary and University of
Sherbrooke through an educational grant
from Pfizer Canada Inc.
Previous Funding: grants/honoraria and
clinical trials with: Valeant, Purdue,
Boehringer, Biogen, Pfizer, Serono, Bayer.
Learning Objectives
Following this course, participants will be
able to:– Give the prevalence and etiologic theories for
fibromyalgia
– List the diagnostic criteria, differential diagnosis
and investigations for fibromyalgia
– Explain the diagnosis to patients with fibromyalgia
in a positive, hopeful and respectful manner
– Provide a treatment strategy for patients
diagnosed with fibromyalgia
– Obtain resources to assist patients in the
management of their fibromyalgia
Clinical Presentation
Patty is a 32-year-old woman in
your practice.
– History:• Under your care for 10 years
• Unremarkable past history
• Slipped on ice 4 months ago and has had
progressive generalized pain and fatigue
• Saw a locum 2 weeks ago who ran a battery of
tests for multiple symptoms of generalized pain,
fatigue and sleep problems
Video Clip
Prevalence of Fibromyalgia
Fibromyalgia occurs in all ages, both
sexes and all cultures, but occurs more
frequently in:– Women
– Patients between the ages of 35 – 60 years
In Canada:– Fibromyalgia affects an estimated 4.9% of adult
women and 1.6% of adult men
– Female to male ratio of approximately 3:1Wolfe et al. Arthritis Rheum. 1995;38:19-28.
Lawrence et al. Arthritis Rheum. 1998;41:778-799.
Neumann et al. Curr Pain Headache Rep. 2003;7:362-368.
Wolfe F. Journal of Musculoskeletal Pain. 1993;3:137-148.
Prescott et al. Scand J Rheumatol. 1993;22:233-237.
Lindell et al. Scand J Prim Health Care. 2000;18:149-153.
Cardiel et al. Clinical and Experimental Rheumatology. 2002;20:617-624.
Carmona et al. Ann Rheum Dis. 2001;60:1040-1045.
White et al. Journal Rheumatol 1999; 26:1570-1576.
• Chronic, widespread pain
is the defining feature
of Fibromyalgia
• Patient descriptors of pain
include: aching, exhausting,
nagging, and hurting
• Presence of tender points
Widespread Pain
• Characterized by nonrestorative sleep
and increased awakenings
• Abnormalities in the continuity of sleep
and sleep architecture
Sleep Disturbance
• Patients describe it as physically
or emotionally draining
Fatigue
Core Clinical Features of Fibromyalgia
Stiffness• Stiffness in the morning is a
common characteristic of
Fibromyalgia
• Characterized by confusion, slowed
processing of information and reaction
time, difficulty in word retrieval or
speaking, concentration, attention,
short-term memory consolidation,
disorientation
Neurocognitive Impairment
(“FibroFog”)
Wolfe et al. Arthritis Rheum. 1995;38:19-28.
Leavitt et al. Arthritis Rheum. 1986;29:775-781.
Wolfe et al. Arthritis Rheum. 1990;33:160-172.
Roizenblatt et al. Arthritis Rheum. 2001;44:222-230.
Harding. Am J Med Sci. 1998;315:367-376.
Henriksson. J Rehabil Med. 2003;(suppl 41):89-94.
Carruthers et al. J Chron Fat Synd. 2003;11:7-115.
Symptoms of Fibromyalgia
Pain, fatigue, and sleep disturbance are
present in at least 86% of patients*
0
20
40
60
80
100
100%96%
86%
72%
60%56%
52%46%
42% 41%
32%
20%
Muscular
pain
Fatigue Insomnia Joint
pains
Head-
aches
Restless
legs
Numbness
and tingling
Impaired
memory
Leg
cramps
Impaired
Concen-
tration
Nervous-
ness
Major
depression
* US data
ACR Fibromyalgia Diagnostic Criteria. National Fibromyalgia Research Association Web site. Available at: http://www.nfra.net/Diagnost.htm.
Accessed October 18, 2007.
Mood Disorders in Fibromyalgia
At time of diagnosis, approximately
20-40% of individuals with fibromyalgia
have an identifiable current mood disorder
(e.g., depression or anxiety)
– Lifetime prevalence of depression: 74%
– Lifetime prevalence of anxiety disorder: 60%
– In many cases, depression or anxiety may be the
result of chronic pain
Katon et al. Ann Intern Med. 2001;134:917-25.
Boissevain et al. Pain. 1991;45:227-38.
Boissevain et al. Pain. 1991;45:239-48.
Giesecke et al. Arthritis Rheum. 2003;48:2916–2922.
Arnold et al. Arthritis Rheum. 2004;50:944–952.
Fishbain et al. Clin J Pain. 1997;13:116–137.
Stressors
Stressors that may trigger fibromyalgia
(supported by case control studies)
– Peripheral pain syndromes
– Physical trauma
– Infections (e.g., parvovirus, EBV, Lyme disease,
Q fever)
– Psychological stress/distress, including sleep
disturbances
Any external noxious stimuli may trigger fibromyalgia, but it is not
a prerequisite for the development of the condition. In many cases,
the onset of fibromyalgia is gradual, with no identifiable trigger.
Clauw et al. Neuroimmunomodulation. 1997;4:134-153.
McLean et al. Med Hypotheses. 2004;63:653-658.
Diagnosing Fibromyalgia: Overview
Patient history of fibromyalgia or related
conditions– Personal history
– Family history
Physical examination– Established diagnostic criteria
– Tender point evaluation
Differential diagnosis– Clinical/laboratory evaluation to exclude other conditions
such as:• Osteoarthritis, rheumatoid arthritis, PMR, hypothyroidism, lupus,
and Sjögren’s syndrome
Note: Extensive lab evaluation is usually not necessary to rule out fibromyalgia. In some cases,
a TSH may be called for. PMR is usually not a problem as it seldom occurs under the age of 60,
whereas the onset of fibromyalgia after 65 is rare.
Mease. J Rheumatol. 2005;32:6-21. Wolfe et al. Arthritis Rheum. 1990;33:160-172.
Assessment of Fibromyalgia: American College of Rheumatology (ACR) Classification Criteria
History of widespread pain
that has been present for
at least 3 months
(ALL of the following
should be present):– Pain on both sides of the body
– Pain above and below
the waist
– Axial skeletal pain
– Pain in at least 11 of
18 tender point sites on digital
palpation
Wolf et al. Arthritis Rheum. 1990;33:160-172.
ACR criteria are both
sensitive (88.4%) and specific (81.1%)
Illustration of Tender Points
Occiput (2) - at the suboccipital muscle insertions
Low cervical (2) - at the anterior aspects of the intertransverse spaces at C5-C7
Trapezius (2) - at the midpoint of the upper border
Supraspinatus (2) - at origins, above the scapula spine near the medial border
Second rib (2) - upper lateral to the second costochondral junction
Lateral epicondyle (2) - 2 cm distal to the epicondyles
Gluteal (2) - in upper outer quadrants of buttocks in anterior fold of muscle
Greater trochanter (2) - posterior to the trochanteric prominence
Knee (2) - at the medial fat pad proximal to the joint line
Wolf et al. Arthritis Rheum. 1990;33:160-172.
Performing a Tender Point Exam
Digital palpation with an approximate force of 4 kg – Estimated pressure needed to turn the examiner’s thumbnail
white upon depressing
For a “positive” tender point, the subject must
state that the palpation was painful
Use of these criteria yielded an 88.4% sensitivity
(measure of correctly diagnosed patients) and an
81.1% specificity (statistical probability of an
accurate negative diagnosis) for diagnosing
fibromyalgia
Controversies regarding tender point evaluation– Subjective
– May not be necessary for diagnostic studies
– What about fewer than 11 of 18 tender points?Wolfe F et al. Arthritis Rheum. 1990;33:160-172.
Tender Points vs. Trigger Points
Tender points:– Painful and tender areas occurring in muscle,
muscle-tendon junction, bursa, or fat pad
– Characteristic of fibromyalgia when they occur
in a widespread manner
Trigger points: – Areas of muscle that are painful to palpation
– Characterized by presence of localized tender
areas and generation of a referral pattern of pain
– Typically occur in a more restricted
regional pattern
– Indicative of myofascial pain syndrome
Borg-Stein et al. Rheum Dis Clin North Am. 1996;22:305-22.
Pathogenesis of Fibromyalgia: Overview
Pathogenesis of fibromyalgia is unknown
Central sensitization is currently the
leading theory – Mechanisms of central sensitization
Excitatory mechanisms
Inhibitory mechanisms
Marchand S. Rheum Dis Clin North Am. 2008;34:285-309.
Pathogenesis of Fibromyalgia
Increased levels of substance P (> 3 x) in
patients with fibromyalgia
fMRI studies show a marked regional
increase in cerebral blood flow following
a painful stimulus in patients with FM
compared to controls not suffering FM
Deficit in the endogenous pain inhibitory
systems noted in fibromyalgia patients
Vaeroy et al. Pain. 1988; 32: 21-26.
Russell et al. Arthritis Rheum. 1994; 37:1593-1601.
Russell et al. In: Russell, ed. Myopain ’95: Abstracts from the 3rd World Congress on Myofascial Pain and Fibromyalgia. San Antonio, Tex; July 30-August 3, 1995.
Gracely et al. Arthritis Rheum. 2002;46:1333-1343.
Julien et al. Pain. 2005;114:295-302.
Should you make a definite diagnosis of fibromyalgia?
Or is the label of fibromyalgia
more harmful to the patient?
Diagnosis Can Improve Patient Satisfaction
Diagnosis of
fibromyalgia improves
health satisfaction– White et al conducted a
prospective, community
comparison of
fibromyalgia patients in
Canada that revealed
significantly improved
scores 36 months
post-diagnosis
– Patients self-reported
health satisfaction on
a 5-point Likert scale
Improvement in Patient Health Satisfaction
Pa
tie
nt
He
alth
Sa
tisfa
ctio
n
3
2.2*
0
1
2
3
4
Baseline Post-diagnosis
Imp
rovem
en
t
5
*Statistically significant versus baseline (Confidence Interval -1.2, -0.4).
White et al. Arthritis Rheum. 2002;47:260-265.
Fate of Patients with Fibromyalgia
In a follow-up study (N=29), Kennedy and Felson found that
all surviving patients still had fibromyalgia 10 years later:
However, 66% indicated some
improvement over the 10 years
0
10
20
30
40
50
60
70
Moderate to
severe pain or
stiffness
Significant
sleeping
difficulties
Notable fatigue Poor global
rating of FMS
symptoms
Successful management requires an upbeat, optimistic approach
and EARLY initiation of effective, individualized therapy – An Australian study of patients provided with a simple treatment regimen
found that 2 years after diagnosis:
– 47% no longer fulfilled Smythe or ACR criteria for fibromyalgia
– Remission identified in 24.2% of assessed patients
% o
f p
ati
en
ts
Reassure patients that fibromyalgia need not be progressive and
that symptoms remain stable over time
Kennedy et al. Arthritis Rheum. 1996;39:682-685.
Wolfe F, Anderson J, Harkness D, et al. Arthritis Rheum. 1997;40:1571-1579.
Bennett R: Web site. Available at: http://www.myalgia.com. Accessed January 25, 2008.
Felson DT, Goldenberg DL. Arthritis Rheum. 1986;29:1522-1526.
Granges G, Zilko P, Littlejohn GO. J Rheumatol. 1994;21:523-529.
Clinical presentation
Some tips on providing the diagnosis
Be specific about the diagnosis
Be positive about the diagnosis
Promote and encourage patient self
efficacy around the disease but…
Set realistic expectations
Emphasize no cure but improved control
of symptoms usually possible
Active treatments generally superior
to passive treatments
Management of Fibromyalgia:Recommended Treatment Approach
Multidisciplinary therapy individualized to patients’
symptoms and presentation is recommended
A combination of non-pharmacological and
pharmacological therapies may benefit most
patients
*Limited evidence for efficacy existsBalneotherapy: treatment of disease or health conditions by bathing
Non-pharmacological Pharmacological
Aerobic exercise
Cognitive behavioral
therapy
Patient education
Strength training
Acupuncture*
Biofeedback*
Balneotherapy*
Non-narcotic analgesics
Analgesic antiepileptics
Antidepressants– TCAs
– SSRIs
– SNRIs
Muscle relaxants
Other
Mease P. Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment. J Rheumatol. 2005;32(suppl 75):6-21.
Carville, Arendt-Nielsen, Bliddal, et al. EULAR evidence based recommendations for the management of fibromyalgia syndrome [published online ahead of print July 20, 2007]. Ann Rheum Dis. Doi:10.1136/ard.2007.071522.
Goldenberg et al. Management of fibromyalgia syndrome. JAMA. 2004;292:2388-2395.
Clauw DJ, Crofford LJ. Chronic widespread pain and fibromyalgia: what we know, and what we need to know. Best Pract Res Clin Rheumatol. 2003;17:685-701.
Arnold LM, Goldenberg DL, Stanford SB, et al. Gabapentin in the treatment of fibromyalgia: a randomized, double-blind, placebo-controlled, multicenter trial. Arthritis Rheum. 2007;56:1336-1344.
Non-pharmacological Treatments With Demonstrated Efficacy Currently in Use
Cognitive-behavioral therapy– Positive effects on coping with and control over pain
• Not proven to improve pain
– Proven to improve physical function
– Should be done by a trained professional
Aerobic and strengthening exercises– Reduce pain, increase self-efficacy, improve QOL, and
reduce depression
– Aerobic exercise should be of low-to-moderate intensity, two
to five times/week
Patient education– Conflicting evidence but some studies have shown
improvements in pain, sleep, fatigue, and quality of lifeVlaeyen JW, Teeken-Gruben NJ, Goossens ME, et al. Cognitive-educational treatment of fibromyalgia: a randomized clinical trial. I: clinical effects. J Rheumatol. 1996;23:1237-1245.
Nicassio PM, Radojevic V, Weisman MH, et al. A comparison of behavioral and educational interventions for fibromyalgia. J Rheumatol. 1997;24:2000-2007.
Williams DA, Cary MA, Groner KH, et al. Improving physical functional status in patients with fibromyalgia: a brief cognitive behavioral intervention. J Rheumatol. 2002;29:1280-1286.
Busch et al. Cochrane Database Syst Rev. 2006.
Brosseau L, Wells GA, Tugwell P, et al.; Ottawa Panel Members. Ottawa Panel evidence-based clinical practice guidelines for strengthening exercises in the management of fibromyalgia: part 2. Phys Ther. 2008;88:873-86.
Brosseau L, Wells GA, Tugwell P, et al.; Ottawa Panel Members. Ottawa Panel evidence-based clinical practice guidelines for aerobic fitness exercises in the management of fibromyalgia: part 1. Phys Ther. 2008;88:857-71.
Pharmacological Therapies for Fibromyalgia
TreatmentLevel of
EvidenceComments
TCAsHigh
– Amitriptyline most widely studied
– Short-term improvements in pain, fatigue, sleep and overall well-
being
– Benefits usually seen 2-4 weeks after initiation of therapy
– Significant side effects, even at low doses
SSRIs Moderate
– Inconsistent data, particularly vs. placebo
– Fluoxetine: improvements in sleep, pain, fatigue and mood at
higher doses
– Paroxetine: improvements in pain, sleep and fatigue, but less
effective than amitriptyline
– Citalopram: improvements in mood at higher doses; appears to
be less effective than fluoxetine and paroxetine
SNRIsHigh (for
duloxetine)
– Duloxetine: improvements in pain, tender points, stiffness and
QOL; approved for fibromyalgia treatment in the US
– Venlafaxine: open label studies show improvements in pain
and mood at doses > 150 mg
TCA: tricyclic antidepressants; SSRIs: selective serotonin reuptake inhibitors; SNRIs: serotonin-norepinephrine reuptake inhibitors
Abeles M, et al. Update on fibromyalgia therapy. Am J Med. 2008;121:555-61. Arnold LM. Biology and therapy of fibromyalgia. New therapies in fibromyalgia. Arthritis Res Ther. 2006;8:212.
Rao SG, Gendreau JF, Kranzler JD. Understanding the fibromyalgia syndrome. Psychopharmacol Bull. 2007;40:24-67 Crofford LJ. Pain management in fibromyalgia. Curr Opin Rheumatol. 2008;20:246-50.
Pharmacological Therapies for Fibromyalgia (continued)
TreatmentLevel of
EvidenceComments
Analgesics/
Antiepileptics High
Pregabalin:
– Improvements in pain, sleep, fatigue and global measures of
change, particularly at dose of 450 mg/day
– Approved for treatment of fibromyalgia in Canada and US
Gabapentin
– Improvements noted in pain, sleep and FIQ scores, but not
number of tender points
Non-narcotic
analgesicsHigh
Tramadol
– Improvements in pain and QOL
– Caution in patients already taking SSRIs or SNRIs due to
potential for serotonin syndrome
Muscle relaxants Moderate
Cyclobenzaprine
– Improvements in pain and sleep; similar outcomes to
amitriptyline
Corticosteroids, strong opioids and NSAIDs have shown no benefit in
patients with fibromyalgia and are NOT recommended.
Abeles M, et al. Update on fibromyalgia therapy. Am J Med. 2008;121:555-61. Arnold LM. Biology and therapy of fibromyalgia. New therapies in fibromyalgia. Arthritis Res Ther. 2006;8:212.
Rao SG, Gendreau JF, Kranzler JD. Understanding the fibromyalgia syndrome. Psychopharmacol Bull. 2007;40:24-67 Crofford LJ. Pain management in fibromyalgia. Curr Opin Rheumatol. 2008;20:246-50.
Carville, et al. Ann Rheum Dis. Doi:10.1136/ard.2007.071522.
Efficacy in the Management of Fibromyalgia
For information regarding active and completed
clinical trials of non-pharmacological and
pharmacological therapies seeking to demonstrate
efficacy in the management of fibromyalgia:
– Visit: www.clinicaltrials.gov, Key Word Search: FIBROMYALGIA
For the latest in scientific literature on the
management of fibromyalgia:
– Visit: http://www.ncbi.nlm.nih.gov/sites/entrez/• Key Word Search: MANAGEMENT OF FIBROMYALGIA
For information regarding approved drugs and
their labeling:
– Visit: http://www.emea.europa.eu/
– Visit: http://www.accessdata.fda.gov/scripts/cder/drugsatfda/
Other Useful Websites/Patient Information
National ME/FM Action Network:http://www.mefmaction.net
Patient Workbooks/Materials:
– Fibromyalgia and Chronic Myofascial Pain: A Survival Manual (2nd Edition)by Devin J. Starlanyl and Mary Ellen Copeland
– The Chronic Illness Workbook: Strategies And Solutions for Taking Back Your Life by Patricia A. Fennell. Albany Health Management Publishing.
– Hope and Help for Chronic Fatigue Syndrome and Fibromyalgia by A.C. Bested & A.C. Logan. Cumberland
House, Nashville, Tennessee.
A Word About Disability…
Many insurers will not accept this diagnosis – the key is to focus
on functional limitations when completing assessments
Consistent, organized, clear documentation over time is powerful
even in the absence of hard medical data
Document:– Objective clinical observations of appearance, behaviour, speech, self-care,
grooming
– Impairments of functioning, work, daily activities, socialization
– Medications prescribed/tried
– Pain levels, physiological distress
– Use additional medical information from consultants
Avoid advocacy statements, personal statements and
non-medical opinions
Emphasize the presence of impairment of functioning over time– For more information see Assessing Occupational Disability
by Dr. I Esche, University of Calgary at:
http://podcast.med.ucalgary.ca/groups/cfs/blog/
Summary
Fibromyalgia occurs in all ages, both sexes and all
cultures, but occurs more frequently in women of
middle age
Core defining features: chronic widespread pain,
sleep disturbance, fatigue, neurocognitive impairment
and stiffness
Establishing the diagnosis of fibromyalgia is an
essential component of successful management
Fibromyalgia need not be progressive and can be
managed successfully through early, individualized
therapy and an optimistic approach by the physician
Treatment includes non-pharmacological and
pharmacological strategies
Local Resources
Arthritis Society (Fibromyalgia Section)
Questions??????
Thank you!